Day 320 A Message to Those of you with stress and Pain

There are many of you out there that are struggling to match over the years. And there are those that are scared and nervous about applying this year. This is a small message of Hope to uplift you and give you strength to keep going.



"PEOPLE NEED THE LORD" song by STEVE GREEN

Everyday they pass me by,
I can see it in their eyes.
Empty people filled with care,
Headed who knows where?

On they go through private pain,
Living fear to fear.
Laughter hides their silent cries,
Only Jesus hears.

People need the Lord, people need the Lord.
At the end of broken dreams, He's the open door.
People need the Lord, people need the Lord.
When will we realize, people need the Lord?

We are called to take His light
To a world where wrong seems right.
What could be too great a cost
For sharing Life with one who's lost?

Through His love our hearts can feel
All the grief they bear.
They must hear the Words of Life
Only we can share.

People need the Lord, people need the Lord
At the end of broken dreams, He's the open door.
People need the Lord, people need the Lord.
When will we realize that we must give our lives,
For peo-ple need the Lord.

People need the Lord.

Another Good Song in Spanish though. "Paz en La Tormenta"
Peace in the Storm



The Greatest Story ever Told (part One)



The Greatest Story Ever Told (Part Two)




God BLess

Dr.Mike

Steps To Christ (Free Download,PDF)
http://www.sdagreymouth.org.nz/PDFs/Steps-to-Christ.pdf

Why Does God Allow Suffering? (video)
http://www.discoveries08.org/episode-4-high-quality

Purchase this song here 1$(99 centz) :
http://mp3.rhapsody.com/steve-green/people-need-the-lord/people-need-the-lord

Day 315 How do I Kill my Beeper ?

Every few times a week the following happens to interns. I would have to say that it happens maybe 1-2 times a week. There is a time during the week where you start getting paged non stop by the nurses and attendings and you are bound to make 1 person un-happy. Its like a juggling act. It gets very hectic to say the least. I will tell you a true scenario of one of those moments.

I would say it started at around 3:30pm

3:31 page 1: "Hi Dr. I just letting you know pt in 205b is upset and want to sign out AMA. Can you come and talk to him?

3:33 Phone call from other intern. "Hey you know that guy in 205b he was in a.fib before but I repeated EKG and he is in sinus now. See if you have a chance to talk with the cardiologist who wanted me to start dig. I gave you a copy of the EKG show it to him if you have a chance . bye"

3:34 Paged again. "hi Dr. can you sign the med rec on the patient you are discharging. Thanks."

3:35 I start walking to the telemetry to see the pt that wants to leave.

3:36 arrive at telemetry. I walk over to the room 205b. Start talking to pt to see what it the situation. While I try to find out why he wants to leave I get another page and 3 cellular phone calls from intern that left.

3:42 I polite interrupt my conversation with the pt. to answer page and phone calls.

3:43 page from e.r wondering if pt can go without monitor for a test.

3:46 As I walk back to try to talk to pt , the nurse taking care of 205b comes up to me and says "did you talk to him? I think he has psych issues. By the way that's the cardiologist behind you. We have been paging him all day. He is an A#$% H_le. "

3:47 I 'm kind of relieved to know that he is an A H_le so that way I can avoid him as best as I can. I wait till he goes to the other room. I answer phone from intern. "You wont believe this. I brought the wrong papers to my appointment. Did you bring papers to your appointment?" I polite say no, but I tell him to call me back if he needs anything.

3:49 I stand a few seconds out side the doctors room deciding whether to talk to the "psycho" attending. I say to myself , let me do it for the pt. I swallow my pride. and show him the EKG. He rarely looks up and says fine. I tell him pt wants to sign out AMA. He says good and keeps writing another note.

3:53 I'm on the phone with the attending of 205b to let him know pt wants to sign out AMA. attending tells me he has psych history. I better check with psych to see if they will clear him to leave AMA.


3:56 I'm on the phone with crisis. "we will try to send someone out to you. But they left for the day. the evening psych might be able to help. the Family resident is standing next to me. "I think I saw him in the other floors."


3:58 I get phone call from my friend again . "Hey sorry to bother you man. Yeah I have to come back and do this again. I didn't bring the paper work. I came for nothing. " (I guess i'll be covering for him again for the third time!)


4:02 I'm walking around the floors to see where the psychiatrist is to ask him about pt. I find him and he tells me that the guy is delusional.

4:04 paged by nurse. whats the story with the 205. I tell her he cant sign out. "Strap him if you have to. do the soft restraints. but better to tell him that psych will come to see him, to see if he can be discharged."

4:06 paged by er again about septic pt. You guys coming to help with the med rec?

4:08 I get to e.r I walk over to nurses station. "there is family members of septic patients that want to talk to me. Nurses supervisor comes up to me and tell me that I should sit down and review 20 medications to see if she is getting the right ones. Other senior comes up to me and ask me about siging line of site of pt that was admitted in the e.r. in the morning for polysubstance abuse. While I sit down to discuss the meds on the septic pt. Other intern stand next to me to sign out his list of patients. I get beeped as I sit down to review septic pts meds. "hi sorry you have and admission. where r u ?" I tell her I'm in e.r

4:10 I read in the progress notes of septic pt that vanco and cancidas were d/c. I go to the computer and delete vaco and cancidas and mistakenly delete 15 other meds !! Now I have to input them before I go to next admission. I sit down and try to do as much of the meds in the computer as I can. another beep comes in from amu to tell me to replace a low magnesium on a pt. As I finish up the list of meds. I realize that the admission I got is from an attending that enjoys having a 1 hour admission talk over the phone. he even wants to know when his patients had the 5th bowel movement when they were 9 yrs old and what color was it. And whats her favorite beverage? what does she eat for lunch? Is she a vegetarian? better check vit b 12.

4:14 I get to bedside of pt that I'm doing admission. the cardiologist is their. I hear something about a murmur. diastolic or something like that. I talk with the cardiologist for a few seconds we did cath on her 5 years ago. Her 2 d echo has worsen. she might need replacement. look up and study indications for valve replacement in asymptomatic pts. I agree to give him a short review later.

418 I sit down with the senior. She is kind of looking at me with a puppy face. you ok? you seem tired. I start looking up labs of patients.. I ask her if she knows the story? she says nothing much just systolic murmur. Maybe some abdominal pain. But she tells me better get orthostatic vitals on her before I call attending. Or try to do a rectal. But she will probably refuse.

420 I walk over to lady who refuses rectal. She denies any abdominal pain on palpitations.

423 "psycho" attending calls back and basically questions every single order that we wanted to do. I say black he says white. I say orange he says apples. I give a brief history of what she told me. He goes into 5 minute story of what he knows about her. Since he's been taking care of her for 110 years and by the way he saw her this morning in the office and last week and had dinner at her has on Saturday. So I finish taking down the orders for the admission. Completely exhausted and upset that I had to end the night talking with this arrogant attending. TO calm myself down I google quotes on patience and wisdom. I find some that make me laugh .

"You are educated when you have the ability to listen to almost anything without losing your temper or self-confidence."
Robert Frost

Patience is something you admire in the driver behind you, but not in one ahead.
Author: Bill Mcglashen

Patience is the greatest of all virtues.

Cato the Elder (234 BC - 149 BC)

"One moment of patience may ward off great disaster. One moment of impatience may ruin a whole life."
Chinese Proverb

4:30 the storm of pages stops for now. After reading quotes on patience, I realize how little I have. I tell myself that its unrealistic to expect all doctors to be the same. There is one bad apple in 100 Its a fact of life and residency. II guess its me that lacks understanding and patience.

SO much for qoutes.

7:30pm 3o minutes to go before I go home. I'm tired

God Bless

Dr.Mike

Day 310 The Sad Side of learning

It was around 530pm in the afternoon and I was on call in the telemetry unit. I had just finished doing an admission when there was a code blue alarm called. "CODE BLUE CCU.... CODE BLUE CCU.." I dropped everything I was doing and ran to the unit. I arrive in about 1 minute and found that there was a patient intubated whose heart rate was in the 190's. When I walked into the room there were 2 seniors (a second and third year.) As I walked into the room,the second year turned to me and said "there is a pulse and she is breathing." There were a group of nurses with the crash cart and respiratory techs standing by. In about another minute or so, the other intern arrived at the room. The other senior turned to us and said "you guys can leave, there is no code blue." The other intern left the room to go back to the e.r. I decided that I wanted to stay to see what they were going to do. I had a page to my beeper and I left to room eager to go back to see how they would handle the situation. As I was on the phone answer a routine call from the floors, I turned to the other intern who was stepping out and said "look at the monitor. She is at 190. You should stick around. When we are seniors, we are going to have to deal with situations like this."

As we were about to start heading back the the unit room, I suddenly hear a group of people clapping or cheering. It seem to be coming from the room where the code blue had been called. I went back to the room to see what was going on, and I see the heart rate at 86. It seems that they had given adenosine 6mg IV x1 and the rate had taken a dramatic dropped. The nurses were so excited and other techs, that they were cheering and clapping about the sudden drop in HR. I felt it was a bit strange. I've never seen people clapping in the middle of a code or a possible code. Over the next 2 minutes her HR when up again. She has a narrow irregular rate Tachycardia. SHe was not in V Tach or V Fib. They gave another adenosine 6mg IVx1 and it broke again. The crowd in the room was less jovial but were a bit relieved that it had gone down. I think the next step was giving adenosine 12mg IVx1 or if she went into V FiB or V tach possible shock?

Anyways, as I walked back to the E.R I thought about what had just happened. I was also excited to have seen what had just happened. I told the intern, "see how much you can learn from these situations. You will rarely forget them. " But the more I thought about it, the more I became a bit sad at what happened. Or at least that fact that some medicine you learn -which is exciting- comes by way of someone else 's misery or misfortune.

I'm not sure if you have been in the middle of a code where people are clapping and cheering with excitement, but it seemed a bit odd.

There is joy in helping people. There is joy in learning something that can better the lives of those around you. There is a sense of deep great emotional fulfillment in medically helping someone that is suffering from diseases. There is a deep joy in giving hope to those that are hopeless, and bringing some light to the darkness of someones life.

Today I went to see a patient in the surgical trauma unit that had a R MCA Stenosis and R internal Carotid occlusion. He is schedule tomorrow possibly for a stenting by the neurosurgeon. As I spoke to him today morning, he seemed a bit nervous. He is a very analytical person. He is an accountant and even writes down and takes note when we do rounds on him. He has 20 questions each time, and is a very well informed individual. We spoke about quitting smoking and possible what was going to happen. As I was about to leave, I had the feeling that I had to say what I was about to tell him. I said " you know MR. Smith. Sometimes certain situations happen in our lives that make us take a step back and make us question what is really important in life. This situation that you are going through might make you look at your life in a different way. You might start to appreciate and realize what is really important in life. Your family your friends. But also you need to remember one thing. Right now you are surrounded by people that care and love you very much. But no one. No one can possible understand fully what you are going through. No one can see your mind and heart. It would have to take someone that is all powerful and knowing to do that. And I believe that someone is God. He is here with you in the darkness moments of your life. He can give you the strength and peace in life to deal with the situation you are going through. He will not abandon you. He is here with you. I don't know how much of a spiritual person you are, but I felt that I had to tell you this. I can sum up my entire life and spiritual walk with one story I heard a long time ago. There was a man in a prison and he was taken to the bathroom by the guard. He grabbed him and threw him down on the toilet and said "clean the toilet with your hands." As the prisoner stood there humiliated and cleaning the toilet with his bare hands, the soldier turned to him and said "where is your GOD?.... Where is your God?" The prisoner looked up to him and said "He is here with me." Sometimes life seems unfair, and it is. Life hurts and you don't understand what you are going through but always remember that God is with you. He will not abandon you. How many times people tell you "where is your GOD?" or How can this happen to you? When you are asked this remember to tell them that God is with you. He will walk with you in these difficult times." I almost had tears in my eyes. And he stared at me. His eyes were wide open. He was very quiet. I turned to him and said "I just that you had to hear that." He turned to me and said "thank you very much for that. I hope that you can come by tomorrow. I turned to him and said "sure.I will see you tomorrow. Good luck tomorrow." I shook is hand and left the room.

I can't describe to you completely how I felt. I felt this deep spiritual strength and satisfaction. It was like an spiritual high. I felt that I had to say those things. He seemed scared and I wanted to give him a bit of hope and a bit of peace. I pray to God that he will have some tomorrow when he undergoes the operation.

I too hope that you have found strength from the difficulties you are facing now in your life. IN your struggle to match and and your struggle to keep going. Keep your head up. God is with you. He will not abandon you. Jesus Loves you very much. Don't give up lean on God for strength. He knows the desire of your heart. Talk and pray to him as you would a friend. He will not forsake you.

God Bless

Dr.Mike

(click on the Below Image)

Day 304 Sixteen Memorable moments of My First year in Residency

Here they are, 16 of them :

16. It happened on my third day of residency. I was called by the nurse to see a patient on the ventilator who was de-saturating. I was being yelled at by the respiratory techs while they asked me what I wanted to do. I was speechless and helpless partly because I had no Idea what to do. You don't learn ventilator management in medical school. I did only what I could do. I got on the phone and scared the living hell out of my senior. I called him and basically almost "cried" to him on the phone....lol. He was in the middle of doing 2 admissions and he came 5 minutes later running. I remember driving home that day scared as hell. I was in a state of quiet shock.

15. I remember the first time I sat down and saw the seniors sign out to each other in the Unit. They ran down about 20 patients in about 5 minutes. Me and the interns were looking at each other saying. "what da hell?".

14. The first patient I ever saw and examined died about 10 minutes later.

13. I still remember when I was back in south New jersey. Living in a 1 room studio with my wife. (We were doing clinical externships in the area.) I remember that I was sitting on the tablei on my computer and my wife stood up and said "you got a pre-match!" I saidd "huh?.... what? Are you kidding me?" She said "look come over and read it." I went over the read the email and it was true. I couldn't believe. "I told you I had a good interview, but I didn't think it was that good...wow." I was so happy. My wife called her mother who was on the phone crying. I called my mom but she wasn't there, so I called my Dad. In fact I called anyone I could think of.It really was amazing.

12. I remember my first day of residency. I sat in the car around 620am and as I drove out of the parking lot. I remember telling myself. "this is truly amazing. I never thought this day would come.

11. I remember when I first pulled into the hospital. I called my mother and told her "you will not believe where I'm at?" She said "where?" I told her I was in the parking lot of the doctors in the hospital. She was like "wow.."

10. I remember when I first woke up to go to residency and my wife had ironed my pants and shirt. And she had woke up early in the morning and I think she made me breakfast and wished me a good day. She was so happy. I later came home that night and she had made me a cake. She is the greatest.

9. I remember the first time I had to do cpr on a patient. The code ran about 20 minutes. After it was over and I left the room. I stopped and looked back and said "I know her." It was a patient who I had talked to about God and hope about 72 hours ago. She had metastatic breast cancer. I rememeber talking to her and telling her "you know. Know one understand what you are going through. Only someone that could see inside your heart and see inside your mind can truly understand what you are going through. And I believe that person is God. He can help you. He will not abandon you. He is with you in these heart times. Lean on God he will help you bear with the difficulties of Life." Who would have known that in 72 hours I would be coding her and she was dying.

8. I remember the chief resident standing up in front of the conference room and telling all the first years "Be ready on day 1. Its gonna start and it will be fast." I really didn't understand what that meant until 3 days later.

7. I remember my first night on call. I was handed about 3 sign outs with 40 patients. I was so scared. And right before I left the floor to go to the lounge for a sec. One of the first year must have seen the expression on my face. He was like "you want me to stay with you? You ok? Come lets talk about it. anything you need let me know." He made me feel at ease. He is really a great Guy. I love him so much. I think he later called me back and asked if I wanted some pizza that he would order for me.

6. I remember finishing my first night on call. Another first year asked me how was my first night on call? I turned to him and said "it was like a medical buffet, and everybody was hungry!" LOL. He smiled and laughed.

5. I will never forget How Dr.Devil went on a rampage in the Unit my first week. (http://thankyougodforresidency.blogspot.com/2008/08/across-your-time-in-wards-and-floors.html) I think ever since that I have been very cautious in approaching attendings. I try to give them their space-especially the Angry ones, and latch on to the ones that are open-minded and love to teach. I remember meeting some extremely humble and approachable attending 's after Dr.Devil and telling myself "what planet do these guys come from?"

4. I never forget the day I realized that all the residents were all equal but the only difference was the experiences they had had. There are a lot of smart and hard working residents, but the only difference is the real life medical situations they have dealt with. Those that had experienced a lot of difficult situations were very prepared and good Doctors.

3. I never forgot how good it felt talking and trying to give hope to those that were dying from a terminal disease . I tried to tell them all that they were not alone. They did not have to deal with this pain by themselves. God was with them. He was going to make up all the badness that they have gone through in life.

2. I never forgot the time that all hell broke lose in the program. http://thankyougodforresidency.blogspot.com/2008/12/day-166-this-is-spartaaaaa.html

Ever since that happened. I have tried to mind my own business and try to work with everyone peacefully.

1. Most of all I remember coming home late from work one night. And sitting in my car. I looked up to my second story apartment. My wife was home and the lights were on. I knew that she had gotten home early and was preparing dinner for me. I remember how good it felt realizing that after 13 years of being with her I still wanted to come home. And I was happy to be there.

Overall I have been very blessed by what God has given me. I only hope that I can give to others the grace and goodness that he has shown me. The good things that happen to us in life, happen so we can share them with others. God gives us purpose so that we can use that purpose to change this world we live in. If God has given me residency, it is only so that I can help others achieve it to. It is to give those who wer ein my same shoes hope. Hope that their lives have purpose and meaning. God will not abandon you. You are not alone in your struggle to finish your careers. Jesus loves you very much. He will guide your path in this long journey you have started. Don't give up. Lean on God for strength.

God Bless

Dr.Mike

"life is not about the moments we breathe

but about the moments

that take our breath away."

Day 302 Drowning

It's 630am in the morning. I just finished another 24 hr call. (This is the 3rd Saturday in the last 4 weeks) I'm a bit exhausted, but I wanted to write down the events of last night. It was a very busy night and very stressful at some points. I was called by a nurse at around 11pm because a patient was desaturating on the floor. She was an elderly lady with chf and pneumonia. I was told over the phone by the nurse that she really didn't look good. I was a bit surprised to hear about it because I was the only resident on the telemetry floor. The admission was done by the other intern and he didn't let me know she was going tho the AMU. What followed next I will never forget.

I went to the telemetry unit to see here. She was extremely anxious, and was saying that she coudn't breath. I check the pulse oximetry and she was at around 80% !! She was about 85yrs old and her code status was AND without intubation. They had her on a non-re breather mask with 100% oxygen. I called respiratory and ordered the usually ABG, EKG, Xray,CMx2. The respiratory tech came and was getting the ABG, and in the meanwhile I called the attending to let her know what was going on. It turns out she was aware that she was really sick and that the family wanted to make possibly comfort measures. I returned to the room, and then all hell broke lose. The patient was now really anxious, she was crying softly and saying "I can't breath !!! HELP ME !! HELP!" I tried to stay calm. I looked at the respiratory tech who had been trying to get the ABG for about 10 minutes (possibly even more). I told him forget the ABG lets put her on high flow oxygen and if we have to we can use bipap. He left the room and went to get the high flow system. I then look over to the lady and she was on the non-re breather mask and she talked slowly and weakly lifts her hands up and try to pull of the facial mask. I try to calm her down. I examined her and even without my stethoscope I could hear the rales. (I had also seen the previous xray of the chest. She has pretty bad CHF , effusion and infiltrate. The xray looked pretty awful!) I loaded her with another does of lasix 40mg IVx1. While we are waiting for the respiratory tech to get the supplies, I try to calm the lady, but then she is starting to cry a bit and keeps looking at me and the nurse "HELP me please... I can't breath." I grabbed her hand and tried to reassure her "WE are going to give you something to breath better. WE are going to give you another mask so you can breath better...ok.." I don't think it help much. She was kicking her legs out and kept on saying "help me..help me." It was so horrible. I got the sense that she probably felt like she was drowning, since she was in CHF and had very bad infiltrates. (She didn't have any severe plueral effusions, in which case she probably would have needed a thoracic tap. I doubt the attending would have agreed to it.) For a minute I wasn't sure what to do. (I didn't want to give her ativan and sedate her.) By this point the other first year had arrived in the room (he had done the admission) He seemed a bit worried. I ordered some respiratory treatments in the meanwhile. I then thought about giving her morphine -for the anxiety properties and for its dilatory properties. I told the nurse to give her 2mg IV morphine, which I placed in the system. By this time about 15minutes passed and we still couldn't find the respiratory tech. The nurse manager walked in, and was upset. "Where is the respiratory tech? He never gets the ABG. He always passes it on to somebody." She went back to the station and started paging the tech. I went back to the room and was trying to comfort the patient. She kept anxiously saying "I can't breath with this mask." We checked the mask to make sure it was working properly. I got the sense that she didn't like how the mask made her feel. I think she felt as if it was suffocating her. And she was acting as if she was "drowning". I tried to stay calm. It wasn't the first time I have seen someone de-saturating and having troubles breathing. And they tend to be a bit lethargic and non responsive. But this is the first time I had someone yelling "PLEASE HELP ME! PLEASE!" While she was on the non-rebreather mask her saturation still was low about 80 percent and fluctuating. Since she kept fighting the mask, we tried to give her Oxygen by nasal canula, but her saturation dropped to about 70%. I wish I could describe to you situation better so that you can get a sense of how this lady was softly screaming and in distress.

A few minutes passed, and finally the respiratory tech appeared with the 100% high flow oxygen system. I told him "lets try the high flow, and if she doesn't improve we can always put her on bipap" He agreed and put her on the high flow system. Its high flow oxygen, but its with a longer nasal tube and has 100 percent high flow oxygen. I didn't want to do bipap yet. I think if she would have seen the bipap mask she would have been extremely agitated. We placed her on the system, and her saturation started to go up around 90%. I check back her meds,and she was on morpine 1mg IV q2h prn. I told the nurse to give her the morphine every two hours so that she can calm down. In about 20 minutes my prayers were answered. ( I had been praying in my head) She was sating around 95 %. And was not acting up. She was calm. It seemed the morphine was having its affect and the high flow really helped. When I saw the situation had calmed, I took a step back and went to the lounge to take a short break and get a cup of water. I felt so relieved. It felt as if I had run a short marathon. I checked back on her in about 30 minutes and she was sleeping comfortably in the room and saturation was 100%. I spoke to the tech to try to titrate down the oxygen, since she was on 100%. He brought it down around 95% and was going down slowly. I also put her on respiratory treatments to help her breath better. (We tried to previous also give her respiratory treatments, but her saturation dropped 80%. )

I hope I tried to explain the situation as best as I could. I'm really glad we were able to help her. Even if its just to help her breath a bit more and so that she won't feel like she is drowning.

Hard to believe how going through scenarios like this you learn to stay calm and try to do certain things to help the patient. If you read my first experience with a similar situation I had in the
Intensive Care unit my first week of residency!! (Day 5 http://thankyougodforresidency.blogspot.com/2008/06/day-5-good-bad-and-ugly.html) They say the long term memory is instilled in you when you have vivid experiences of them. The more unpredictable and different the situation is, the more you remember it. Some of the most stressful moments I have had, have also been the most educational.

For those that are starting residency soon. Work hard and be a good active participant in your residency. Stay close to a senior you can talk medicine with. You will have seniors that you don't feel comfortable asking certain things because you don't want to seem stupid. But find the seniors that are patient and are able to help you out in any situation. You will see that the more situations you encounter, the more you will feel comfortable.

It's 8:30 in am now, I'm gonna try to get some rest.

God Bless

Dr.Mike